Provider Demographics
NPI:1255489506
Name:MAYNARD, PETER ELWOOD (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:ELWOOD
Last Name:MAYNARD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 BISCUIT CITY RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02881-1604
Mailing Address - Country:US
Mailing Address - Phone:401-789-3741
Mailing Address - Fax:
Practice Address - Street 1:347 BISCUIT CITY RD
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:RI
Practice Address - Zip Code:02881-1604
Practice Address - Country:US
Practice Address - Phone:401-789-3741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS 146103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIR64401Medicare UPIN